by James C. Sherlock
I congratulate UVa Children’s Hospital for taking a step forward in the treatment of gender dysphoric minors.
One of the criticisms of that service was its singular focus on endocrinology.
Moving from mental health support to hormone therapy is, as Mayo Clinic warns, a big step.
Starting this week, comprehensive services in the Teen & Young Adult Health Center Transgender Health Services will for the first time include treatment by clinical psychologists of gender dysphoric minors for anxiety, depression and ongoing emotional issues.
UVa Children’s has added Professor Laura Shaffer, Ph.D., the chief of the hospital’s section of pediatric psychology, to the staff of that service. She is joined there by Assistant Professor Haley Stephens, Ph.D. and Assistant Professor Sara Groff Stephens, Ph.D.
This welcome change should ensure:
- that a child arriving at that clinic will be thoroughly and professionally assessed and treated by a clinical psychologist;
- that no child is referred to hormone treatment who can be effectively treated with psychotherapy; and
- that both the minor and his parents will fully understand the risks of hormone therapy and, while being supportive, the psychologist will emphasize to parents the importance of allowing their child the freedom to return to a gender identity that aligns with his or her sex assigned at birth.
Psychologist approach.
Professor Schaffer served her internship in Child Clinical and Pediatric Psychology at Children’s National Medical Center, and then conducted a two-year postdoctoral fellowship in adolescent health promotion and prevention research at the National Institute of Child Health and Human Development.
She promises to be a formidable presence in the clinic.
The approach of the psychologist in treating gender dysphoric minors is affirming but careful.
The American Psychological Association in its Guidelines for Psychological Practice With Transgender and Gender Nonconforming People (TNCP) is well-stocked with “on the one hand” guidance. It emphasizes that the psychologist treating TNCP minors is working in a developing field and a challenging one.
It alerts that many adolescents and their parents arrive at a clinic demanding instant access to hormones.
From Guidelines:
Adolescents can become intensely focused on their immediate desires, resulting in outward displays of frustration and resentment when faced with any delay in receiving the medical treatment from which they feel they would benefit and to which they feel entitled.
This intense focus on immediate needs may create challenges in assuring that adolescents are cognitively and emotionally able to make life-altering decisions to change their name or gender marker, begin hormone therapy (which may affect fertility), or pursue surgery.
This confirms the doubts of many citizens concerning whether the minor and his parents can be in an appropriate emotional state to make such life-changing decisions.
The psychologist is guided to psychoanalysis to assure that hormone treatment is indicated. And this:
Adolescents and their families may need support in tolerating ambiguity and uncertainty with regard to gender identity and its development.
Emphasizing to parents the importance of allowing their child the freedom to return to a gender identity that aligns with sex assigned at birth or another gender identity at any point cannot be overstated, particularly given the research that suggests that not all young gender nonconforming children will ultimately express a gender identity different from that assigned at birth.
Endocrinologist approach.
The careful approach recommended for psychologists stands in stark contrast to the Endocrine Society, which points to a perhaps illusory and certainly self-serving “evolving consensus that being transgender is not a mental health disorder.”
It asserts: “data are strong for a biological underpinning to gender identity.”
The Endocrine Society’s Clinical Practice Guideline on gender dysphoria/gender incongruence provides the standard of care for supporting transgender individuals. The guideline establishes a methodical, conservative framework for gender-affirming care, including pubertal suppression, hormones and surgery and standardizes terminology to be used by healthcare professionals.
Good to know that these off-label experiments on minors are “methodical and conservative.”
The new presence of clinical psychologists in the clinic at UVa Children’s should help prevent the headlong rush to hormones that was the message of the clinic until this week.
Many, I among them, do not approve of hormone therapy for minors under any conditions because of:
- the unknown long-term effects of hormones unapproved by the FDA for this use in off-label in experiments on minors;
- the ongoing investigation into infertility effects and other hazards of puberty blockers. Even the Endocrine Society admits that:
further studies are needed to determine strategies for fertility preservation and to investigate long-term outcomes of early medical intervention, including pubertal suppression, gender-affirming hormones and gender-affirming surgeries for transgender/gender incongruent youth.
- the psychological distress caused by the physical effects of puberty blockers on already mentally distressed minors;
- the high statistical probability that a patient using puberty blockers will proceed to cross-gender hormones;
- the known infertility effects of the cross-gender uses of estrogen and testosterone; and
- the moral hazard of the life-altering procedure on minors too young to give approval.
That said, UVa Children’s has taken a step forward.
I congratulate them for it.
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